Article Text

Original research
Administration approaches of nursing assistants in hospitals: a scoping review
  1. Ben-tuo Zeng1,
  2. Yinghui Jin2,
  3. Shu-dong Cheng3,
  4. Yan-ming Ding4,
  5. Ji-wei Du5
  1. 1School of Medicine, Xiamen University, Xiamen, Fujian, China
  2. 2Center for Evidence-Based and Translational Medicine, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China
  3. 3Nursing Department, Xiang'an Hospital of Xiamen University, Xiamen, Fujian, China
  4. 4Nursing Department, Peking University First Hospital, Beijing, China
  5. 5Nursing Department, The University of Hong Kong-Shenzhen Hospital, Shenzhen, Guangdong, China
  1. Correspondence to Dr Ji-wei Du; dujw{at}


Objectives The administration of nursing assistants (NAs) is closely associated with patient outcomes, but studies evaluating intrahospital administration of NAs are limited. This study aimed to identify existing literature on intrahospital NAs’ administration approaches.

Design Scoping review.

Data sources PubMed, Embase, CINAHL, Scopus, ProQuest, CNKI, APA PsycInfo, Wanfang Med, SinoMed, Ovid Emcare, NICE, AHRQ, CADTH, JBI EBP and Cochrane DSR were searched for articles published between January 2011 and March 2022.

Eligibility criteria for selecting studies Qualitative, quantitative or mixed-method studies and evidence syntheses that evaluate administration approaches, models and appraisal tools of intrahospital NAs were included.

Data extraction and synthesis Two independent reviewers conducted search, data selection and data extraction according to Joanna Briggs Institute guidance and methodology for scoping review. The quality of included studies was assessed using Mixed Methods Appraisal Tool or AMSTAR V.2. Data were synthesised using narrative methods and frequency effect size analysis.

Results Thirty-six studies were eligible, with acceptable quality. We identified 1 administration model, 9 administration methods, 15 educational programmes and 7 appraisal tools from the included studies. The frequency effect size analysis yielded 15 topics of the main focus at four levels, suggesting that included articles were mainly (33%) focused on the competency of NAs, and the lectures were the most (80%) used strategy in quality improvement projects. Evidence from the studies was of low-to-moderate quality, indicating huge gaps between evidence-based research and management practice.

Conclusions Practical intrahospital administration approaches were revealed, and fifteen primarily focused topics were identified. We should explore this area more thoroughly using structured frameworks and standardised methodology. This scoping review will help managers find more effective ways to improve the quality of care. Researchers may focus more on evidence-based practice in NA administration using the 15 topics as a breakthrough.

  • Quality in health care
  • Human resource management

Data availability statement

All data relevant to the study are included in the article or uploaded as online supplemental information. All data relevant to the study are included in the article or uploaded as online supplemental information, and the protocol of this study are openly available (DOI: 10.13140/RG.2.2.29106.12483/1).

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:

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Strengths and limitations of this study

  • First scoping review of practical administration approaches for nursing assistants (NAs) in hospitals.

  • Presenting the main topics and focus of related articles.

  • Development of the NA administration was widely varied among countries.

  • Most of the included studies were of moderate-to-low methodological quality, and a huge gap exists between evidence-based research and management practice.


Nursing assistants (NAs) are trained allied nursing personnel who provide or assist with basic care or support under the direction of onsite licensed nursing staff.1 In 2019, there were approximately 1.73 million NAs in the USA, and this number in the European Union was 4.67 million in 2018,2 3 indicating that NAs have become the mainstay of care. As an integral part of routine healthcare, NAs are providing more care in hospitals due to the increasing ageing population and the shortage of registered nurses (RNs) in recent years,4 5 thereby raising the criticality of NA administration. Nursing administration is now challenged by diverse educational backgrounds and the communication and connection between NAs and RNs.6–8

Standards and regulations of NAs have been established in several countries, for example, OBRA 1987 Act in the USA,9 the Cavendish Review and other documents in the European Union10 11 and the Care Certificate in the UK.12 And in China, the National Health Commission emphasised the standardised regulation of NAs in 2019, providing instructions on NA training.13 However, the documents provided requirements for NA education, qualifications and training, but not for broader administration settings. There have not been uniform intrahospital NA administration regulations across countries.

The efficacy of the miscellaneous administration approaches followed by healthcare facilities was vague, leading to the grim current circumstances of NA administration. Lack of crucial competency, high turnover rate, low vocational identity and low self-efficiency confused NAs and their administrators.14–19 The faultiness of these aspects would directly affect the quality of care. A higher turnover rate was associated with fewer infection events, and the retention rate was positively linked with clinical outcomes.20 21 The self-efficacy of NAs was associated with their burnout rate, which was very dangerous for care outcomes.22 In addition, communication among NAs, other nursing staff and administrators also needed improvement. NAs reported discontentment with administrators’ not understanding their work problems,23 and the performance of NAs also was influenced by relationships among NAs, RNs and other clinical staff.24

Various definitions, duties and unbalanced development of NAs worldwide25 26 have created barriers to identifying appropriate management strategies. In the USA, NAs are also named certified NAs (CNAs) and unlicensed assistive personnel and the names were nurse/nursing aides (NAs), healthcare assistants (HCAs) and nursing auxiliaries in the UK. Nursing attending workers (NAW) and NAs were used in China.26 The communication of research from different countries is always confusing, and valid approaches and practices are needed to address the current chaos.

NAs take up several care duties that directly affect the outcomes of patients in hospitals. However, much of the previous research on nursing administration was developed in long-term care settings, and limited studies have been conducted in hospitals. Due to the scarcity of primary studies, organising systematic reviews or other evidence syntheses is challenging, and therefore scoping reviews are needed and timely to identify existing evidence and assess the feasibility of conducting evidence-based research. In this article, we reviewed available administration approaches and assessment tools for NAs in inpatient care settings, described the current progress of this field and presented a vision for further research and evidence synthesis.

Aims and research questions

This review aimed to identify, describe and synthesise current knowledge and the existing literature on NAs’ administration approaches and models, as well as education, skill training and multidimensional appraisal in hospitals. Two research questions were raised for intrahospital NA administration:

  • What are the available approaches, models, programmes and tools?

  • What are the most focused topics and most used methods of the existing studies?


Study design and protocol

The review was conducted according to Joanna Briggs Institute (JBI) guidance and methodology for scoping review27 28 and reported using the Preferred Reporting Items for Systematic reviews and Meta-analyses—Extension for Scoping Reviews (PRISMA-ScR).29 A structured protocol30 was prepared a priori according to the PRISMA Protocols 2015 statement and explanation31 32 and PRISMA-ScR.

Eligibility criteria

This review was designed to identify studies that mainly focused on NAs and discussed at least one administration-related topic. The inclusion criteria were:

  1. Participants: NAs (or certificated NAs, nurse aides, etc).

  2. Setting: hospital.

  3. Study type: qualitative, quantitative or mixed researches, evidence-based reviews, guidelines, consensus or related dissertations.

  4. Focus: specific approaches or models, or overall administration models, programmes, tools or frameworks.

  5. Methodology: reported clear intervention/exposure methods and evaluation tools.

  6. Language: English or Chinese.

  7. Peer-reviewed studies published between January 2011 and March 2022.

The exclusion criteria were:

  1. Participants: other healthcare personnel, students or orderlies; or mixed participants with different occupations, and NAs were not discussed or presented separately.

  2. Focus: focusing on specific areas, and the conclusions were only fit for the focused areas.

  3. Setting: long-term care facilities, nursing homes or skilled nursing facilities.

  4. Outcome: not reported key administrational outcomes.

Search strategy and study selection

For initial screening, we retrieved comprehensive, medical, nursing and evidence-based databases as follows: medical databases (PubMed, Embase, APA PsycInfo, Wanfang Med and SinoMed), nursing databases (CINAHL and Ovid Emcare), general databases (Scopus, ProQuest and CNKI) and evidence-based practice databases (NICE, AHRQ, CADTH, JBI EBP and Cochrane DSR). The initial search was completed in November 2021, and we updated the results in March 2022.

We ran a preliminary search in PubMed to identify keywords, search fields and related topics. We used PubMed PubReMiner33 to identify related keywords for search strategy establishment. Afterwards, search strategies in each database were developed, including key terms: nursing assistants, nursing aides, nursing auxiliar*, administr*, educat*, training, apprais*, organization and administration. Full search strategy is displayed in online supplemental file 1. References of all included studies were manually searched using terms ‘assistant’ and ‘aide’.

All publications were imported into EndNote V.20.2 (build 15709) for citation management and duplicates were removed. A brief screening checklist (online supplemental file 2) was developed for study selection to minimise the inconsistency of the reviewers. Two reviewers screened all the studies independently according to the eligibility criteria. Divergences were discussed by the reviewers together or with a third researcher.

Data charting

Article characteristics, sample size and participant demographics, focused topics, study designs and outcomes were charted from eligible studies. Two researchers designed a structured data charting tool (online supplemental file 3) for data charting and continuously refined it. Data charting of all eligible studies was performed by two authors independently and was corroborated by a third researcher.

Quality appraisal

The Mixed Methods Appraisal Tool (MMAT) V.201834 35 was applied for qualitative, quantitative or mixed-methodological studies. AMSTAR V.2, a critical appraisal tool for systematic reviews,36 was used for the critical appraisal of evidence-based reviews. An overall score was carried out for each included study. For the MMAT, we calculated the percentage of items answered ‘yes’ in section 2, and for AMSTAR V.2, after items that were not applicable were excluded, we conducted a grade of overall confidence according to the criteria by Shea et al36

Data synthesis

Eligible studies were divided into administration approaches, education and training and appraisal tools. We summarised the study types, main focus and detailed intervention/exposure measures for the administration, education and training fields. For studies on practical tools, detailed tool information and psychometrics were extracted. For further interpretation, we conducted a frequency effect size analysis of the area of the main focuses and intervention strategies based on the calculating effect size method from the metasummary methodology introduced by Sandelowski et al37

Patient and public involvement

It was not appropriate or possible to involve patients or the public in the design, or conduct, or reporting, or dissemination plans of our research.


The search identified 1973 related studies, among which 538 were Chinese publications. Overall, 138 publications remained for full-text screening, where 103 articles were excluded (see online supplemental file 4). Thirty-five studies from databases were included in the scoping review, and one study published from 2011 to 2021 were manually identified from the reference lists. Ultimately, we identified 36 eligible studies38–73 for our scoping review (figure 1).

Figure 1

Preferred Reporting Items for Systematic reviews and Meta-analyses flow diagram for study selection.

Study characteristics

Study characteristics and contents are displayed in table 1. Settings, limitations, fundings and competing interests of the studies are shown in online supplemental file 5.

Table 1

Study characteristics

The articles were mainly from the USA and China, and 22 of 36 studies were published in the last 5 years (2017–2022). Overall, 2 theses, 3 evidence syntheses and 31 original research papers were included. Overall, 25 articles presented quantitative designs (17 interventional and eight descriptive), 1 was qualitative and 7 studies employed mixed methods. Most studies (19 of 24) with interventions applied a quasiexperimental, pretest and post-test design, while 1 study57 presented a retrospective post-then-pretest design.74 Focus group interviews were the most employed method in qualitative and mixed methods studies. The three evidence syntheses were in different types: one integrated review,40 one qualitative metasummary44 and one systematic review.46

All 33 original studies were conducted in hospitals due to our inclusion criteria, and the sample size ranged from 6 to 700 NAs. Three studies45 64 71 were focused on patients’ attitudes and did not report the demographics of NAs. Only one study54 reported a higher than 60% response rate, while others ranged from 10% to 40%.

The methodological quality appraisal results of the studies are listed in online supplemental file 6. The mean score of all 33 original studies assessed by the MMAT reached a level of 65%, and for evidence-based reviews, 2 of the studies40 44 received a ‘very low’ rating, while the other 146 got a ‘high’. Overall, the methodological quality of the included studies was considered acceptable.

Approaches and models

Fourteen studies addressed various administration approaches and focuses, as listed in table 2. The development of NA administration in China was still preliminary, and articles by Chinese researchers were more fixated on employment models. Five studies43 45 51 68 71 were aimed at the change of management and employment from company led to hospital led, or double track, with consistently positive results on satisfaction and NA/NAW working competency after intervention. Other original studies identified four practical tools or methods, that is, the Failure Modes and Effects Analysis (FMEA),52 the Activities of Daily Living (ADL) Scale,59 the Quality Control Circle (QCC)69 and an information sheet to patients,73 as well as two programmes on stress and CNA–patient relationships.41 58

Table 2

Administration approaches, training and education programmes, appraisal tools and main focuses (n=36)

Negative outcomes were found in turnover rates after a CNA orientation coach62 and in adverse events with the addition of assistants in nursing (AINs) to acute wards.64 Meanwhile, several approaches, including crew resource management, the TeamSTEPPS programme75 and the SBART shift model, were summarised by an integrated review from Campbell et al40

Education and training programs

Each of the 13 research papers developed an education programme with different topics, while two evidence reviews44 46 discussed educational strategies on palliative care and workplace aggression with wide availability (table 2). NA knowledge and skills were most emphasised. Six studies highlighted five aspects of NA competency: patient handling,50 67 palliative care,44 dementia,57 restorative care60 and routine work capacity.55 Of other studies, two53 63 improved patient safety, two56 65 were on communication, two61 66 pointed to continuing education and the other two46 72 focused on self-protection. The strategies taken ranged from classical lectures to web-based learning, simulation and practical training. The mixed outcome of education on workplace aggression was reviewed by Geoffrion et al,46 addressing the need of further study in this area.

Appraisal tools

We found seven valid appraisal tools for NA administration with stable psychometrics from the included studies (table 2):

  1. HCA and RNs’ intention questionnaire.38

  2. A seven-item leader–member exchange relational quality questionnaire from Campbell et al39 and developed by Graen and Uhl-Bien.76

  3. NA working questionnaire.47

  4. The Nursing Culture Assessment Tool.49

  5. The Structured Multidisciplinary Evaluation Tool from Haraldsson et al48 and developed by Haraldsson in 2016.77

  6. Self-Efficacy for Preventing Falls—Assistants.42

  7. The Work Ability Index from Monteiro et al54 and produced by Ilmarinen.78

Three of seven papers developed original scales and tested reliability and validity. Four studies examined the psychometrics of existing questionnaires or applied questionnaires to NA administration and reported eligible outcomes. The main focuses ranged from working capacity and workload to relationships, intentions and nursing culture.

Frequency effect size analysis

We conducted frequency effect size analysis on the included studies’ main focuses and strategies (table 3 and online supplemental file 7 figure S1). Fifteen main focuses were identified at four levels. The most reported focuses were competency at the NA level (frequency effect size 33%), communication and clinical staff satisfaction (both 14%) at the clinical personnel level and patient satisfaction (25%) at the patient level. Both topics at the fourth facility management level (retention and care quality control) were at a 6% level of effect size.

Table 3

Frequency effect size analysis of main focuses and intervention methods

Twenty studies contained the theme of education and training strategies. Face-to-face lectures were still the most employed method (80%), followed by simulation, role play and practical training (30%). We also noted that flyers with various knowledge and skills for CNA continuing education were designed by Ward et al,66 which was a unique and effective method not adopted by other studies. Due to the significant heterogeneity, we failed to distinguish themes in studies on NA administration methods and only summarised their objectives. Approximately 62% of the studies evaluated tools for administration, and the other five papers were on hospital management models (38%).


This review outlined existing administration tools, management models, education programmes and appraisal scales from previous studies. The results implied a need to investigate more on administration models and frameworks for NA administration in hospitals. High-quality evidence of the efficacy of existing educational strategies was scarce. Gaps in NA administration development and current circumstances between developed and developing areas were noted and needed improvement.

Approaches and models

Existing articles for administration approaches, models and frameworks were scarce. Only 14 studies presented evaluations on these topics, and the focuses were region-specific, that is, researchers from China and the Europe–US region typically targeted different objectives.

In China, NAWs were employed by companies or hospitals, or were self-employed.79 80 The company employment model took the majority.81 The selection and training of NAWs were conducted by directors and executors of companies but not clinical professionals, leading to uncontrolled quality of care and muddled management.79 82 The researchers proposed to improve this context. Included Chinese studies showed a three-tiered hierarchical model where NAWs were managed by (1) nurse departments or NAW centres, (2) head nurses and (3) ward nurses. However, this review revealed remarkable heterogeneity and unrepresentative sampling in this area. Further investigation of the hospital management model and the effectiveness of other mature models in Chinese hospitals can be the next step.

Chinese researchers also evaluated the FMEA model, ADL Scale and QCC. FMEA and QCC were widely used mature models in hospital routine management,83–86 but have rarely been evaluated for NAs. However, without any new points added, the ideas were only a panning from nurses to NAs. On the other hand, the application of ADL Scale was more innovative. ADL was first developed by Katz87 and is one of the most widely used tools for assessing patient functions. Different ADL scores and levels represented patients’ statuses and care needs to guide managers to a more cost-effective and patient-oriented model of NA allocation.

For researchers from the countries where NA industry has been highly developed, a holistic programme was typically their focus. They also focused on more humanistic aspects such as communication, workload, safety, etc. They41 58 developed or evaluated programmes to improve administration, that is, the TeamSTEPPS programme, BREATHE programme and the Care Partner Programmes. The programmes were well-designed and of good availability, but the small sample size still placed barriers to their widespread application. Additional studies on approaches to widen the applicability and design of more diverse programmes are crucial.

The difference in the hotspots of the research area was strongly related to the degree of development of NA industry in different regions. Our included studies were strongly demand driven. In a region where NA regulations were not yet well-established, relevant studies tended to be more primary and discuss basic administration structures, for example, employment modes. On the contrary, in countries where NAs were mandated by law to be employed and managed by healthcare institutes themselves, the topic was no longer necessary for research, and researchers have turned to explore more advanced knowledge.

Educational strategies

Overall, 11 groups of educational strategies were applied to 20 included studies. In total, 90% of the studies employed at least two groups of strategies, with an average of 2.60, and multiple education methods may result in more positive outcomes compared with single-method teaching.88 A simulation was highlighted because it has been shown to be effective in nursing education,89 90 and a debrief simulation method was recommended.91 Web-based training has become a modern trend, especially during the COVID-19 pandemic.92 However, the evidence regarding the effectiveness of e-learning in nursing education remains unclear.93 94 Moreover, half of the articles used interactive methods, for example, simulation, discussion and group study. We found this to be a trend in NA education and training in recent years. When transferring these teaching methods to NAs, attention should be paid to the educational background gap between NAs and nursing students.

Focuses and topics

Overall, 23 focuses were initially found by the frequency effect analysis, where 15 topics were distilled. NA knowledge and skills were most widely considered, with a trend of being more specified for improving competency. Most of the studies conducted an on-the-job training mode, thus the necessity of exploring advanced competency to avoid repeats. Focuses that contributed smaller effect sizes may denote the possible directions of future studies. NA intentions, relationships of NA–other nursing staff and NA–patients, workload, stress and retention in hospitals needed more investigation. Existing studies revealed that all of the factors above influenced the quality of care at the RN or nursing home level,95–98 but evidence of influence and improvement methods of NAs in hospitals is limited.

A noteworthy point was that much of the research in this area of NA was essentially a transposition of methods previously applied among RNs to NAs, within all three fields this review investigated. FMEA, QCC and patient satisfaction were significant examples. However, as discussed above, researchers should be very careful when dealing with the differences in educational background and job content between RNs and NAs.

Negative outcomes

Three studies46 62 64 reported notable negative or mixed outcomes. The systematic review from Geoffrion et al46 supposed that both patients and healthcare workers may not benefit from educational programmes on workplace aggression for clinical staff, revealing that other approaches or the education for patients may be conducted for the improvement of NA safety. Swann62 evaluated the influence of the CNA orientation coaches on the retention rate and derived a negative result, while Twigg et al64 placed an analysis of adding AINs to acute care wards with unexpected outcomes on failure to rescue, urinary tract infection and falls. The sample of the latter two articles was still limited, with the potential risk of inadequate study designs (observational study to evaluate the interventions), so researchers may conduct more studies on their topics in spite of the discouraging results.


Several gaps were concluded for the NA administration area: (1) NA definitions, regulations and circumstances varied widely among countries, especially between high income and those with moderate-to-low incomes, which created barriers to global evidence and practical experience shared processes. (2) The limited sample sizes and non-randomised study designs of the included studies may decrease the reliability of outcomes. (3) The included studies were of low-to-moderate quality of evidence and availability, and the study design was not reported in-detailed. There were barriers between existing studies and evidence-based practice. (4) Theories and conceptual frameworks were often neglected in the study designs.


The diversified intervention methods of the included studies led to significant heterogeneity, so barriers existed for further analysis and synthesis. We included only Chinese and English articles, while studies published in other languages were excluded, thus leading to a potential risk of bias. Furthermore, more studies may not be included for analysis in other social sciences databases, as NA administration is a broad, multidisciplinary and interdisciplinary topic. We also noted that 3 included evidence-based reviews addressed 32 original studies, where 13 studies were published between 2011 and 2022 but were not included in our scoping review, implying a potential risk of incomprehensiveness of our work.


This scoping review demonstrated the practical administration approaches and focus from previous studies for hospital NAs. The review found a total of 9 administration methods, 1 administration model, 15 education and training programmes and 7 appraisal tools. With the frequency effect size analysis, 15 main focus groups and 11 educational strategies used for improving administration were outlined. The insight from our review will add knowledge to effective NA administration for hospital managers and head nurses and help to improve the quality of care with increasing evidence.

Barriers remain between the intrahospital NA administration area and evidence-based nursing research and practice. The endeavour to apply evidence-based methods to administration will be arduous but will contribute greatly to improved outcomes.

We expect that the administration approaches concluded by our study will help leaders interpret more about effective management to improve quality of care and benefit all clinical staff and patients. The difference between hospitals and long-term care settings should be recognised, and more studies on NAs in hospitals are expected. Researchers should draw more attention to evidence-based methods in the administration area, resulting in continuous improvement, global sharing and system establishment of intrahospital NAs’ administration.

Data availability statement

All data relevant to the study are included in the article or uploaded as online supplemental information. All data relevant to the study are included in the article or uploaded as online supplemental information, and the protocol of this study are openly available (DOI: 10.13140/RG.2.2.29106.12483/1).

Ethics statements

Patient consent for publication

Ethics approval

Not applicable.


We acknowledge Ms. Zhuo Lin and Ms. Zhang Yu-jing for their ideas on study design, data synthesis and manuscript refinement.


Supplementary materials


  • Contributors B-tZ and S-dC performed study selection, data charting and quality appraisal. B-tZ and YJ completed the study design, search, data synthesis and preparation of the manuscript. Y-mD refined the overall study design, conducted the frequency effect size analysis and prepared the manuscript. Any raised disagreement was discussed and solved by B-tZ, S-dC, YJ and J-wD. All authors (B-tZ, YJ, S-dC, Y-mD and J-wD) contributed to the revision and refinement of the manuscript. B-tZ was the guarantor of this study, and she accepted full responsibility for the finished work and/or the conduct of the study, had access to the data, and controlled the decision to publish.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.